MEDICARE: DR. SUSAN BENNETT PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	749	OR

General Provider Information

NPI Number	:	1972623510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN BENNETT PHD

Provider Business Mailing Address
First Line	:	4915 N INTERSTATE AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217-3624
Country	:	US
Telephone Number	:	503-705-3852
Fax Number	:

Provider Business Practice Location Address
First Line	:	4915 N INTERSTATE AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217-3624
Country	:	US
Telephone Number	:	503-705-3852
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	07/08/2007

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